Age shock index and age-modified shock index are valuable bedside prognostic tools for postdischarge mortality in ST-elevation myocardial infarction patients

BACKGROUND

The incidence of mortality is considerable after ST-elevation myocardial infarction (STEMI) hospitalization; risk assessment is needed to guide postdischarge management. Age shock index (SI) and age modified shock index (MSI) were described as useful prognosis instruments; nevertheless, their predictive effect on short and long-term postdischarge mortality has not yet been sufficiently confirmed.

METHODS

This analysis included 3389 prospective patients enrolled from 2016 to 2018. Endpoints were postdischarge mortality within 30 days and from 30 days to 1 year. Hazard ratios (HRs) were evaluated by Cox proportional-hazards regression. Predictive performances were assessed by area under the curve (AUC), integrated discrimination improvement (IDI), net reclassification improvement (NRI) and decision curve analysis (DCA) and compared with TIMI risk score and GRACE score.

RESULTS

The AUCs were 0.753, 0.746 for age SI and 0.755, 0.755 for age MSI for short- and long-term postdischarge mortality. No significant AUC differences and NRI were observed compared with the classic scores; decreased IDI was observed especially for long-term postdischarge mortality. Multivariate analysis revealed significantly higher short- and long-term postdischarge mortality for patients with high age SI (HR: 5.44 (2.73-10.85), 5.34(3.18-8.96)), high age MSI (HR: 4.17(1.78-9.79), 5.75(3.20-10.31)) compared to counterparts with low indices. DCA observed comparable clinical usefulness for predicting short-term postdischarge mortality. Furthermore, age SI and age MSI were not significantly associated with postdischarge prognosis for patients who received fibrinolysis.

CONCLUSIONS

Age SI and age MSI were valuable instruments to identify high postdischarge mortality with comparable predictive ability compared with the classic scores, especially for events within 30 days after hospitalization.

Impact of controlled blood pressure and pulse rate at discharge on clinical outcomes in patients with ST-segment elevation myocardial infarction

BACKGROUND

Although major guidelines recommend the routine introduction of angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs) and beta-blockers for patients with ST-segment elevation myocardial infarction (STEMI), evidence regarding the target blood pressure (BP) or pulse rate (PR) at hospital discharge is sparse. This retrospective study aimed to compare the clinical outcomes in patients with STEMI between those with good BP and PR control and those with poor BP or PR control.

METHODS

We included 748 patients with STEMI who received both ACE inhibitors/ARBs and beta-blockers at hospital discharge, and divided them into a good control group (systolic BP ≤140 mmHg and PR ≤80 bpm, n = 564) and a poor control group (systolic BP >140 mmHg or PR >80 bpm, n = 184). The primary endpoint was major cardiovascular events (MACE) defined as the composite of all-cause death, non-fatal myocardial infarction, and re-admission for heart failure.

RESULTS

During the median follow-up duration of 568 days, a total of 119 MACE were observed. The Kaplan-Meier curves showed that MACE were more frequently observed in the poor control group (p = 0.009). In the multivariate Cox hazard analysis, the good control group was inversely associated with MACE (HR 0.656, 95 % CI: 0.444-0.968, p = 0.034) after controlling for multiple confounding factors.

CONCLUSIONS

The good control of systolic BP and PR at discharge was inversely associated with long-term adverse events in STEMI patients treated with both ACE inhibitors/ARBs and beta blockers. This study suggests the importance of titration of ACE inhibitors/ARBs and beta-blockers for better clinical outcomes in patients with STEMI.

Prevalence and Predictors of Emergency Medical Service Use in Patients Undergoing Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction

AIM

We aim to describe prevalence of Emergency Medical Service (EMS) use, investigate factors predictive of EMS use, and determine if EMS use predicts treatment delay and mortality in our ST-elevation myocardial infarction (STEMI) cohort.

METHOD

We prospectively collected data on 5,602 patients presenting with STEMI for primary percutaneous coronary intervention (PCI) transported to PCI-capable hospitals in Victoria, Australia, from 2013-2018 who were entered into the Victorian Cardiac Outcomes Registry (VCOR). We linked this dataset to the Ambulance Victoria and National Death Index (NDI) datasets. We excluded late presentation, thrombolysed, and in-hospital STEMI, as well as patients presenting with cardiogenic shock and out-of-hospital cardiac arrest.

RESULTS

In total, 74% of patients undergoing primary PCI for STEMI used EMS. Older age, female gender, higher socioeconomic status, and a history of prior ischaemic heart disease were independent predictors of using EMS. EMS use was associated with shorter adjusted door-to-balloon (53 vs 72 minutes, p<0.001) and symptom-to-balloon (183 vs 212 minutes, p<0.001) times. Mode of transport was not predictive of 30-day or 12-month mortality.

CONCLUSIONS

EMS use in Victoria is relatively high compared with internationally reported data. EMS use reduces treatment delay. Predictors of EMS use in our cohort are consistent with those prevalent in prior literature. Understanding the patients who are less likely to use EMS might inform more targeted education campaigns in the future.

Impact of triglyceride-glucose index on intracoronary thrombus burden in ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention

BACKGROUND AND AIMS

We aimed to investigate the relationship between triglyceride glucose (TyG) index and intracoronary thrombus burden in patients with ST-elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (PCI).

METHODS AND RESULTS

A total of 468 consecutive patients who were admitted with STEMI and underwent primary PCI were included in the study. TyG index was calculated as ln [fasting triglycerides (mg/dL) × fasting plasma glucose (mg/dL)/2]. According to the angiographic reclassified thrombolysis in myocardial infarction (TIMI) thrombus grade, patients were divided into two groups as small thrombus burden (STB) with TIMI thrombus grade 0-3, and large thrombus burden (LTB) with TIMI thrombus grade 4-5. TyG index was significantly higher in the LTB group than in the STB group (9.11 ± 0.86 vs 8.89 ± 0.62; p = 0.002). In multivariate analysis, TyG index was found to be an independent predictor of LTB in STEMI patients who underwent primary PCI [OR (95 % CI): 1.470 (1.090-1.982), p = 0.012]. The area under the curve (AUC) of TyG index predicting LTB was 0.568 (95 % CI 0.506-0.631; p = 0.023), with the best cut-off value of 8.87. In the classification according to TyG index cut-off value, the frequency of LTB was found to be significantly higher in the high TyG index group than in the low TyG index group (33.6 % vs 21.2 %; p = 0.003).

CONCLUSION

TyG index, a valid surrogate marker of insulin resistance, is an independent predictor of LTB in STEMI patients who underwent primary PCI and can be used as an indicator of increased intracoronary thrombus burden.

The non-HDL-C/HDL-C ratio is a strong and independent predictor of the no-reflow phenomenon in patients with ST-elevation myocardial infarction

BACKGROUND

No-reflow (NR) is the inability to achieve adequate myocardial perfusion despite successful restoration of attegrade blood flow in the infarct-related artery after primary percutaneous coronary intervention. The non-HDL-C/HDL-C ratio has been shown to be superior to conventional lipid markers in predicting most cardiovascular diseases. In this study, we wanted to reveal the predictive value of the NR by comparing the Non-HDL-C/HDL-C ratio with traditional and non-traditional lipid markers in patients who underwent primary percutaneous coronary intervention (pPCI) due to ST-elevation myocardial infarction (STEMI).

METHODS

A total of 1284 consecutive patients who underwent pPCI for STEMI were included in this study. Traditional lipid profiles were detected and non-traditional lipid indices were calculated. Patients were classified as groups with and without NR and compared in terms of lipid profiles.

RESULTS

No-reflow was seen in 18.8% of the patients. SYNTAX score, maximal stent length, high thrombus burden, atherogenic index of plasma and non-HDL-C/HDL-C ratio were determined as independent predictors for NR (p < 0.05, for all). The non-HDL-C/HDL-C ratio predicts the development of NR in STEMI patients with 71% sensitivity and 67% specificity at the best cut-off value. In ROC curve analysis, the non-HDL-C/HDL-C ratio was superior to traditional and non-traditional lipid markers in predicting NR (p < 0.05, for all).

CONCLUSION

The non-HDL-C/HDL-C ratio can be a strong and independent predictor of NR in STEMI patients and and therefore non-HDL-C/HDL-C ratio may be a useful lipid-based biomarker that can be used in clinical practice to improve the accuracy of risk assessment in patients with STEMI.

Age and gender mediated the association between anemia and 30-day outcomes in patients with ST-segment elevated myocardial infarction

Background

The higher prevalence of anemia in females and elderly may be attributed to its association with worsened outcomes in ST-elevation myocardial infarction (STEMI) patients. We aimed to evaluate the precise effects of age and gender on the association between anemia and 30-day outcomes.

Method

We identified 4350 STEMI patients and divided into anemia and non-anemia. Effects were analyzed as categories using Cox proportional-hazards regression and as continuous using restricted cubic splines. Propensity score matching (PSM) and mediation analysis were applied to identify intermediate effects.

Results

Anemic patients were older, more likely to be female, and experienced doubled all-cause death (7.3 % versus 15.0 %), main adverse cardiovascular and cerebrovascular events (MACCE, 11.1 % versus 20.2 %), heart failure (HF, 5.1 % versus 8.6 %), and bleeding events (2.7 % versus 5.4 %). After adjustment, the association between anemia and all-cause death (Hazard ratio (HR) 1.15, 95 % confidence interval (95 %CI) 0.93-1.14), MACCE (HR 1.14, 95 %CI 0.95-1.36) and HF (HR 1.19, 95 %CI 0.92-1.55) were insignificant, the effects persisted nullified across age classes (P-interaction > 0.05) and PSM (P > 0.05). Ulteriorly, age mediated 77.6 %, 66.2 %, 48.0 %, gender mediated 38.1 %, 15.0 %, 3.2 %, age and gender together mediated 99.8 % 72.9 %, 48.1 % of the relationship. Anemia was independently associated with bleeding events (HR 2.02, 95 %CI 1.42-2.88), the effects consisted significant regardless of PSM (P < 0.05), age, and gender classes (P-interaction > 0.05), and no mediating role of age and gender were observed.

Conclusions

In STEMI patients, age and gender largely mediated the relationship between anemia and all-cause death, MACCE, and HF, anemia was independently associated with bleeding complications.

Association Between Platelet Glycoprotein IIb/IIIa Inhibition and In-Hospital Outcomes in ST-Elevation Myocardial Infarction Patients Treated with Coronary Thrombus Aspiration: Findings from the CCC-ACS Project

PURPOSE

Thrombus aspiration in ST-elevation myocardial infarction (STEMI) with high thrombus burden did not improve clinical outcomes. The clinical efficacy of the bailout use of platelet glycoprotein IIb/IIIa inhibitors (GPIs) in this clinical scenario remains unknown.

METHODS

We assessed associations between GPI use and in-hospital major bleeds, ischemic events, and mortality among STEMI patients treated with percutaneous coronary intervention (PCI) and thrombus aspiration in a nationwide acute coronary syndrome registry (the Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome project).

RESULTS

A total of 5896 STEMI patients who received thrombus aspiration were identified, among which 56.3% received GPI therapy. In a 1-to-1 propensity-score-matched cohort, compared with STEMI patients not treated with GPI, GPI use was associated with a 69% increase in major in-hospital bleeds, with an odds ratio (OR) of 1.69, a 95% confidence interval (CI) of 1.08 to 2.65, and a nonsignificant reduction in ischemic events (OR: 0.61, 95% CI: 0.36 to 1.06), as well as a neutral effect on mortality (OR: 0.93, 95% CI: 0.55 to 1.58). However, among patients aged < 60 years, GPI use was associated with a reduction in ischemic events (OR: 0.27, 95% CI: 0.08 to 0.98), and no significant increase in major bleeds was observed.

CONCLUSION

In a nationwide registry, routine use of GPI following thrombus aspiration was not associated with reduced in-hospital ischemic events and mortality but at the cost of increased major bleeding. However, for patients aged < 60 years, there may be a potential net benefit.

Cardiogenic Shock Prior to Percutaneous Coronary Intervention in ST-Elevation Myocardial Infarction: Outcomes and Predictors of Mortality (ANZACS-QI 73)

BACKGROUND & AIMS

Cardiogenic shock (CS) is a serious complication of acute myocardial infarction (MI) and is associated with significant mortality. We describe a contemporary, real-world cohort of patients with ST-elevation MI (STEMI) and CS, including 30-day mortality and clinically relevant predictors of mortality.

METHODS

All patients presenting with STEMI who were treated with percutaneous coronary intervention (PCI) in New Zealand (2016 to 2020) were identified from the Aotearoa New Zealand All Cardiology Services Quality Improvement (ANZACS-QI) registry and stratified based on their Killip class on arrival to the cardiac catheterisation laboratory. Primary outcome was 30-day all-cause mortality. Multivariable analysis was used to identify predictors of mortality prior to PCI and to develop a mortality scoring system.

RESULTS

In total, 6,649 patients were identified, including 192 (2.9%) Killip IV (CS) patients. Thirty-day mortality was 47.5% in patients with CS, 14.6% in those with heart failure without shock, and 3% in those without heart failure. Independent predictors of 30-day mortality for patients with CS were: estimated glomerular filtration rate <60 mL/min/1.73m2 (relative risk [RR] 1.89, 95% confidence interval [CI] 1.39-2.58), cardiac arrest (RR 1.54, 95% CI 1.15-2.06), diabetes (RR 1.31, 95% CI 1.01-1.70), female sex (RR 1.32, 95% CI 1.01-1.72), femoral arterial access (RR 1.42, 95% CI 1.06-1.90) and left main stem culprit (RR 2.16, 95% CI 1.65-2.84). A multivariable Shock score was developed which predicts 30-day mortality with good global discrimination (area under the curve 0.79, 95% CI 0.73-0.85).

CONCLUSION

In this national cohort, the 30-day mortality for STEMI patients presenting with CS treated with PCI remains high, at nearly 50%. The ANZACS-QI Shock score is a promising tool for mortality risk stratification prior to PCI but requires further validation.

Role of low-density lipoprotein electronegativity and sexual dimorphism in contributing early ventricular tachyarrhythmias following ST-elevation myocardial infarction

Background

Early ventricular tachycardia/fibrillation (VT/VF) in patients with ST-elevation myocardial infarction (STEMI) has higher morbidity and mortality. This study examines gender-differentiated risk factors and underlying mechanisms for early onset VT/VF in STEMI.

Methods

We analyzed data from 2,964 consecutive STEMI patients between January 1, 2008 and December 31, 2021. Early VT/VF was defined as occurrence of spontaneous VT/VF of ≥30 s or requirement of immediate cardioversion/defibrillation within the first 48 h after symptoms. An ex vivo ischemic-reperfusion experiments were conducted in 8-week-old ApoE-/- mice fed a high-fat diet to explore the underlying mechanisms of early VT/VF.

Results

In 255 of out 2,964 STEMI patients who experienced early VT/VF, the age was younger (58.6 ± 13.8 vs. 61.0 ± 13.0 years old, P = 0.008) with a male predominance. The plasma levels of L5, the most electronegative subclass of low-density lipoprotein, was higher in early VT/VF patients compared to those without early VT/VF (n = 21, L5: 14.1 ± 22.6% vs. n = 46, L5: 4.3 ± 9.9%, P = 0.016). In the experimental setup, all male mice (n = 4) developed VT/VF post sham operation, whereas no such incidence was observed in the female mice (n = 3). Significantly, male mice exhibited considerably slower cardiac conduction velocity as compared to their female counterparts in whole heart preparations (25.01 ± 0.93 cm/s vs.42.32 ± 5.70 cm/s, P < 0.001), despite analogous action potential durations. Furthermore, isolated ventricular myocytes from male mice showed a distinctly lower sodium current density (-29.20 ± 3.04 pA/pF, n = 6) in comparison to female mice (-114.05 ± 6.41 pA/pF, n = 6, P < 0.001). This decreased sodium current density was paralleled by a reduced membrane expression of Nav1.5 protein (0.38 ± 0.06 vs. 0.89 ± 0.09 A.U., P < 0.001) and increased cytosolic Nav1.5 levels (0.59 ± 0.06 vs. 0.29 ± 0.04 A.U., P = 0.001) in male mice. Furthermore, it was observed that the overall expressions of sorting nexin 27 (SNX27) and vacuolar protein sorting 26 (VPS26) were significantly diminished in male mice as compared to female littermates (0.91 ± 0.15 vs. 1.70 ± 0.28, P = 0.02 and 0.74 ± 0.09 vs. 1.57 ± 0.13, P < 0.01, respectively).

Conclusions

Our findings reveal that male STEMI patients with early VT/VF are associated with elevated L5 levels. The gender-based discrepancy in early VT/VF predisposition might be due to compromised sodium channel trafficking, possibly linked with increased LDL electronegativity.

Linkage of CDC42 and T-helper cell ratio with anxiety, depression and quality of life in ST-elevation myocardial infarction

Objective: To investigate the correlations between CDC42 and T-cell subsets concerning anxiety, depression and quality of life in ST-elevation myocardial infarction patients undergoing percutaneous coronary intervention. Methods: Sera from 156 participants were analyzed for CDC42 levels and Th1, Th2, Th17 and Treg cells. Results: CDC42 correlated with reduced Th1/Th2 and Th17/Treg ratios, lower anxiety and depression, and higher EuroQol visual analog scale (EQ-VAS) score. The Th17/Treg ratio correlated with elevated anxiety, depression, EuroQol-5 dimensions score and decreased EQ-VAS score. The Th1/Th2 ratio was positively related to the EQ-VAS score. Conclusion: CDC42 correlates with reduced Th1/Th2 and Th17/Treg ratios, reduced anxiety and depression, and improved quality of life in ST-elevation myocardial infarction patients undergoing percutaneous coronary intervention.

The value of computed tomography for head trauma in patients presenting with out-of-hospital cardiac arrest before emergency percutaneous coronary intervention

INTRODUCTION

Out-of-hospital cardiac arrest (OHCA) caused by an ST-elevation myocardial infarction (STEMI) is often accompanied by a sudden loss of consciousness that may cause the patient to collapse with resulting head trauma, leading to a suspicion of possible intracranial haemorrhage. To rule out intracranial haemorrhage before emergency percutaneous coronary intervention (PCI), emergency computed tomography (CT) of the head might be useful but also causes a delay in percutaneous STEMI treatment.

METHODS

The medical records of all adult patients that presented with OHCA to the emergency department (ED) of the University Medical Centre Utrecht (UMCU), the Netherlands between 16 February 2020 and 16 February 2022 were reviewed.

RESULTS

A total of 263 patients presented to the ED with an OHCA; 50 presented with a STEMI requiring emergency PCI. Thirty-nine (78%) patients with a STEMI were immediately referred to the catheterisation laboratory and 11 (22%) STEMI patients underwent a CT scan prior to emergency angiography; in no case was PCI deferred on the basis of the CT findings. The dominant indication for CT of the head was collapse, reported by 10 patients and resulting in a visible traumatic head injury in 7 patients. In none of the patients was intracranial haemorrhage detected. However, there was a delay between presentation to the ED and arrival at the catheterisation laboratory in patients who underwent CT of the head (mean 63 ± 25 min) before emergency PCI compared to patients without a CT scan (mean 37 ± 21 min).

CONCLUSION

CT of the head did not result in a diagnosis of intracranial haemorrhage or deferral of PCI but did delay PCI treatment for STEMI in patients presenting with OHCA.

Effects of triglyceride glucose (TyG) and TyG-body mass index on sex-based differences in the early-onset heart failure of ST-elevation myocardial infarction

BACKGROUND AND AIM

Heart failure (HF) is an important complication of ST-elevation myocardial infarction (STEMI), including early- and late-onset HF. This study aimed to investigate the association between insulin resistance (IR)-related parameters triglyceride glucose (TyG) and TyG-body mass index (TyG-BMI) index and early-onset HF in STEMI between sexes.

METHODS AND RESULTS

This cross-sectional study included patients with STEMI who underwent primary percutaneous coronary intervention (PCI) between January 2016 and September 2022. Patients were divided into tertiles according to TyG/TyG-BMI index levels in males and females. The presence of early-onset HF was compared between tertiles in both sexes. Moreover, patients were stratified according to the tertiles of TyG/Tyg-BMI index. Differences in early-onset HF of STEMI were compared between males and females in each tertile group. 1118 patients were included in this study, 20.3% of whom were females. The incidence rate of early-onset HF was significantly higher in females than in males (29% vs. 14.8%). TyG-BMI index was negatively correlated with early-onset HF. In both females and males, there was no difference in the occurrence of early-onset HF between the highest and lowest TyG/TyG-BMI index groups. Sex disparity was observed in females who had a significantly higher prevalence of early-onset HF than males in each TyG/TyG-BMI index tertile group; however, after adjustment, the differences disappeared.

CONCLUSIONS

For patients with STEMI who undergo primary PCI, the incidence of early-onset HF is higher in females than in males. The TyG/TyG-BMI index do not contribute to the difference in early-onset HF between sexes.

Determinants and Prognoses of Visual-Functional Mismatches After Mechanical Reperfusion in ST-Elevation Myocardial Infarction

Background

Discordance between the anatomy and physiology of the coronary has important implications for managing patients with stable coronary disease, but its significance in ST-elevation myocardial infarction has not been fully elucidated.

Methods

The retrospective study involved patients diagnosed with ST-elevation myocardial infarction (STEMI) who underwent percutaneous coronary intervention (PCI), along with quantitative coronary angiography (QCA) and quantitative flow ratio (QFR) assessments. Patients were stratified into four groups regarding the severity of the culprit vessel, both visually and functionally: concordantly negative (QCA-diameter stenosis [DS] ≤ 50% and QFR > 0.80), mismatch (QCA-DS > 50% and QFR > 0.80), reverse mismatch (QCA-DS ≤ 50% and QFR ≤ 0.80), and concordantly positive (QCA-DS > 50% and QFR ≤ 0.80). Multivariable logistic regression analyses were conducted to identify the clinical factors linked to visual-functional mismatches. Kaplan‒Meier analysis was conducted to estimate the 18-month adverse cardiovascular events (MACE)-free survival between the four groups.

Results

The study involved 310 patients, with 68 presenting visual-functional mismatch, and 51 exhibiting reverse mismatch. The mismatch was associated with higher angiography-derived microcirculatory resistance (AMR) (adjusted odds ratio [aOR]=1.016, 95% CI: 1.010-1.022, P<0.001). Reverse mismatch was associated with larger area stenosis (aOR=1.044, 95% CI: 1.004-1.086, P=0.032), lower coronary flow velocity (aOR=0.690, 95% CI: 0.567-0.970, P<0.001) and lower AMR (aOR=0.947, 95% CI: 0.924-0.970, P<0.001). Additionally, the mismatch group showed the worst 18-month MACE-free survival among the four groups (Log rank test p = 0.013).

Conclusion

AMR plays a significant role in the occurrence of visual-functional mismatches between QCA-DS and QFR, and the mismatch group showed the worst prognosis.

Systemic Immune-Inflammation Index and Systemic Inflammatory Response Index as Predictors of Mortality in ST-Elevation Myocardial Infarction

(1) Background: The systemic inflammatory response index (SIRI; neutrophil count × monocyte/lymphocyte count), and the systemic immune-inflammation index (SII; platelet count × neutrophil count/lymphocyte count) are recently proposed biomarkers to assess the immune and inflammatory status. However, data on SIRI and SII are still relatively lacking and do not definitively and exhaustively define their role as predictors of an adverse prognosis in acute myocardial infarction (AMI). The aim of the present study was to evaluate SII and SIRI determinants as well as to assess SIRI and SII prognostic power in ST-elevation myocardial infarction (STEMI). (2) Methods: A total of 105 STEMI patients (74 males, 70 ± 11 years) were studied (median follow-up 54 ± 25 months, 24 deaths). (3) Results: The main determinants of SIRI and SII were creatinine and brain natriuretic peptide (BNP) (multivariate regression). Patients with higher SIRI (>75th percentile, 4.9) and SII (>75th percentile, 1257.5) had lower survival rates than those in the low SIRI/SII group (Kaplan-Meier analysis). Univariate Cox regression revealed that high SIRI and SII were associated with mortality (HR: 2.6, 95% CI: 1.1-5.8, p < 0.05; 2.2, 1-4.9, p ≤ 0.05, respectively); however, these associations lost their significance after multivariate adjustment. (4) Conclusions: SIRI and SII association with mortality was significantly affected by confounding factors in our population, especially creatinine and BNP, which are associated with both the inflammatory indices and the outcome.

Impact of Contrast-Associated Acute Kidney Injury on One-Year Outcomes in Very Elderly STEMI Patients: Insights From a Multicenter Registry in Northern Italy

Data about contrast-associated acute kidney injury (CA-AKI) in oldest old (age ≥85 years) ST-elevation myocardial infarction (STEMI) patients are scarce. We evaluated the incidence and the 1-year prognostic impact of CA-AKI in this population. Patients were included in a multicenter real-world registry, and CA-AKI was defined according to KDIGO (Kidney Disease Improving Global Outcomes) criteria. Major adverse cardiac and cerebrovascular events (MACCEs) were defined as the composite of all-cause death, stroke, unplanned coronary revascularization, and heart failure hospitalization. The primary outcome was the incidence and impact of CA-AKI on MACCEs at 1 year follow-up. Out of 461 STEMI patients (mean age 88.6 ± 2.9 years), 102 (22.1%) patients developed CA-AKI. Chronic kidney disease was the strongest predictor of CA-AKI (odds ratio [OR]: 4.52, 95% CI: 2.81-7.30, P < .01). The CA-AKI cohort showed a higher risk of MACCEs (adjusted HR: 1.75, 95% CI: 1.13-2.71, P = .01), driven mainly by all-cause death (adjusted hazard ratio [HR]: 2.39, 95% CI: 1.41-4.07, P = .01) and followed by heart failure hospitalization (adjusted HR: 2.01, 95% CI: 1.08-3.76, P = .01). Among oldest old STEMI, CA-AKI was frequent and associated with a higher incidence of MACCEs at 1-year follow-up.

Prognostic Value of Segmental Strain After ST-Elevation Myocardial Infarction: Insights From the EARLY Assessment of MYOcardial Tissue Characteristics by Cardiac Magnetic Resonance (EARLY-MYO-CMR) Study

BACKGROUND

The prognostic value of left ventricular segmental strain (SS) in ST-elevation myocardial infarction (STEMI) remains unclear.

HYPOTHESIS

To assess the prognostic value and application of SS.

STUDY TYPE

Retrospective analysis of a prospective registry.

POPULATION

Five hundred and forty-four patients after STEMI (500 in Cohort 1, 44 in Cohort 2).

FIELD STRENGTH/SEQUENCE

3 T, balanced steady-state free precession, gradient echo, and gradient echo contrast-enhanced images.

ASSESSMENT

Participants underwent cardiac MR during the acute phase after STEMI. Infarct-related artery (IRA) strain was determined based on SS obtained from cine images. The primary endpoint was the composite of major adverse cardiovascular events (MACEs) after 8 years of follow-up. In Cohort 2, SS stability was assessed by MR twice within 8 days. Contrast and non-contrast risk models based on SS were established, leading to the development of an algorithm.

STATISTICAL TEST

Student's t-test, Mann-Whitney U-test, Cox and logistic regression, Kaplan-Meier analysis, net reclassification index (NRI). P < 0.05 was considered significant.

RESULTS

During a median follow-up of 5.2 years, 83 patients from Cohort 1 experienced a MACE. Among SS, IRA peak circumferential strain (IRA-CS) was an independent factor for MACEs (adjusted hazard ratio 1.099), providing incremental prognostic value (NRI 0.180, P = 0.10). Patients with worse IRA-CS (>-8.64%) demonstrated a heightened susceptibility to MACE. Additionally, IRA-CS was significantly associated with microvascular obstruction (MVO) (adjusted odds ratio 1.084) and infarct size (r = 0.395). IRA-CS showed comparable prognostic effectiveness to global peak circumferential strain (NRI 0.100, P = 0.39), also counterbalancing contrast and non-contrast risk models (NRI 0.205, P = 0.05). In Cohort 2, IRA-CS demonstrated stability between two time points (P = 0.10). Based on risk models incorporating IRA-CS, algorithm "HJKL" was preliminarily proposed for stratification.

DATA CONCLUSIONS

IRA-CS is an important prognostic factor, and an algorithm based on it is proposed for stratification.

LEVEL OF EVIDENCE

4 TECHNICAL EFFICACY: Stage 2.

Structural Complications Following ST-Elevation Myocardial Infarction: An Analysis of the National Inpatient Sample 2016 to 2020

ST-elevation myocardial infarction (STEMI) is a life-threatening emergency that can result in cardiac structural complications without timely revascularization. A retrospective study from the National Inpatient Sample included all patients with a diagnosis of STEMI between 2016 and 2020. Primary outcomes of interest were in-hospital mortality, length of stay (LoS), and healthcare costs for patients with and without structural complications. There were 994,300 hospital admissions included in the analysis (median age 64 years and 32.2% female). Structural complications occurred in 0.78% of patients. There was a three-fold increase in patients with cardiogenic shock (41.6% vs. 13.6%) and in-hospital mortality (30.6% vs. 10.7%) in the group with structural complications. The median LoS was longer (5 days vs. 3 days), and the median cost was significantly greater (USD 32,436 vs. USD 20,241) for patients with structural complications. After adjustments, in-hospital mortality was significantly greater for patients with structural complications (OR 1.99, 95% CI 1.73-2.30), and both LoS and costs were greater. There was a significant increase in mortality with ruptured cardiac wall (OR 9.16, 95% CI 5.91-14.20), hemopericardium (OR 3.20, 95% CI 1.91-5.35), and ventricular septal rupture (OR 2.57, 95% CI 1.98-3.35) compared with those with no complication. In conclusion, structural complications in STEMI patients are rare but potentially catastrophic events.

Reperfusion strategies on the clinical outcomes of ST-elevation myocardial infarction patients over 80 years old in China

BACKGROUNDS AND AIMS

This study aims to explore the efficacy of reperfusion strategies on the clinical outcomes of ST-elevation myocardial infarction (STEMI) patients over 80 years old in China.

METHODS

A retrospective cohort study was performed on STEMI patients over 80 years old who underwent reperfusion strategies and no reperfusion between January 2014 and December 2021 based on the China Cardiovascular Association (CCA) Database-Chest Pain Center.

RESULTS

This study included a total of 42,699 patients (mean age 84.1 ± 3.6 years, 52.2% male) among which 19,280 (45.2%) underwent no reperfusion, 20,924 (49.0%) underwent primary percutaneous coronary intervention (PCI), and 2,495 (5.8%) underwent thrombolytic therapy. After adjusting for potential confounders, multivariable logistic regression analysis revealed that patients who underwent primary PCI strategy showed a significantly lower risk of in-hospital mortality (OR = 0.62, 95% CI: 0.57-0.67, P < 0.001) and the composite outcome (OR = 0.83, 95% CI: 0.79-0.87, P < 0.001) compared to those received no reperfusion. In contrast, patients with thrombolytic therapy exhibited a non-significantly higher risk of in-hospital mortality (OR = 0.99, 95% CI: 0.86-1.14, P = 0.890), and a significantly elevated risk of the composite outcome (OR = 1.15, 95% CI: 1.05-1.27, P = 0.004). During a median follow-up of 6.7 months post-hospital admission, there was a percentage 31.4% of patients died and patients in the primary PCI group consistently demonstrated a reduced incidence of all-cause mortality (HR = 0.58, 95% CI: 0.56-0.61, P < 0.001).

CONCLUSION

STEMI patients over 80 years old who underwent the primary PCI strategy are more likely to have favorable clinical outcomes compared to those who received no reperfusion, whereas, thrombolytic therapy warrants careful assessment and monitoring.

The predictive value of laboratory parameters for no-reflow phenomenon in patients with ST-elevation myocardial infarction following primary percutaneous coronary intervention: A meta-analysis

To date, the predictive role of laboratory indicators for the phenomenon of no flow is unclear. Hence, our objective was to conduct a meta-analysis to investigate the association between laboratory parameters and the risk of the no-reflow phenomenon in patients with ST-elevation myocardial infarction (STEMI) following primary percutaneous coronary intervention (PCI). This, in turn, aims to offer valuable insights for early clinical prediction of no-reflow. We searched Pubmed, Embase, and Cochrane Library from the establishment of the database to October 2023. We included case-control or cohort study that patients with STEMI following primary PCI. We excluded repeated publication, research without full text, incomplete information or inability to conduct data extraction and animal experiments, reviews, and systematic reviews. STATA 15.1 was used to analyze the data. The pooled results indicated that elevated white blood cell (WBC) count (odds ratio [OR] = 1.061, 95% confidence interval [CI]: 1.013-1.112), neutrophil count (OR = 1.324, 95% CI: 1.128-1.553), platelet (PLT) (OR = 1.002, 95% CI: 1.000-1.005), blood glucose (OR = 1.005, 95% CI: 1.002-1.009), creatinine (OR = 1.290, 95% CI: 1.070-1.555), total cholesterol (TC) (OR = 1.022, 95% CI: 1.012-1.032), d-dimer (OR = 1.002, 95% CI: 1.001-1.004), and fibrinogen (OR = 1.010, 95% CI: 1.005-1.015) were significantly associated with increased risk of no-reflow. However, elevated hemoglobin was significantly associated with decreased risk of no-reflow. In conclusion, our comprehensive analysis highlights the predictive potential of various parameters in assessing the risk of no-reflow among STEMI patients undergoing PCI. Specifically, WBC count, neutrophil count, PLT, blood glucose, hemoglobin, creatinine, TC,  d-dimer, and fibrinogen emerged as significant predictors. This refined risk prediction may guide clinical decision-making, allowing for more targeted and effective preventive measures to mitigate the occurrence of no-reflow in this patient population.

Initial treatment of uninsured patients with ST-elevation myocardial infarction by facility percutaneous coronary intervention capabilities

BACKGROUND

Timely reperfusion is necessary to reduce morbidity and mortality in patients with ST-elevation myocardial infarction (STEMI). Initial care by facilities with percutaneous coronary intervention (PCI) capabilities reduces time to reperfusion. We sought to examine whether insurance status was associated with initial care at emergency departments (EDs) with PCI capabilities among adult patients with STEMI.

METHODS

We conducted a retrospective cross-sectional study using Department of Healthcare Access and Information, a nonpublic statewide database reporting ED visits and hospitalizations in California. We included adults initially arriving at EDs with STEMI by diagnostic code (International Classification of Diseases Ninth Revision or 10th Revision) from 2011 to 2019. Multivariable logistic regression modeling included initial care by PCI capable facility as the primary outcome and insurance status (none vs. any) as the primary exposure. Covariates included patient, facility, and temporal factors and we conducted multiple robustness checks.

RESULTS

We analyzed 135,358 eligible visits with STEMI included. In our multivariable model, the odds of uninsured patients being initially treated at a PCI-capable facility were significantly lower than those of insured patients (adjusted odds ratio 0.62, 95% CI 0.54-0.72, p < 0.001) and was unchanged in sensitivity analyses.

CONCLUSIONS

Uninsured patients with STEMI had significantly lower odds of first receiving care at facilities with PCI capabilities. Our results suggest potential disparities in accessing high-quality and time-sensitive treatment for uninsured patients with STEMI.

Association Between History of Polymerase Chain Reaction-verified COVID-19 Infection and Outcomes of Subsequent ST-Elevation Myocardial Infarction

While the acute phase of coronavirus disease 2019 (COVID-19) is associated with worsening cardiac outcomes, it is unclear whether it affects the outcome of patients with ST-segment elevation myocardial infarction (STEMI) after the acute phase. In addition, while many studies compared the course of STEMI during the COVID-19 pandemic with the years before the outbreak, we evaluated the course of STEMI during the pandemic according to whether or not patients had history of COVID-19. Patients diagnosed with STEMI during the ongoing COVID-19 pandemic were included in the study. The Ministry of Health database was analyzed retrospectively, and patients with (n = 191) and without (n = 127) a history of polymerase chain reaction (PCR) confirmed COVID-19 infection were divided into groups. Clinical and angiographic characteristics were assessed. The rates of in-hospital major adverse cardiac events (MACE) were higher in those who had a history of PCR-verified COVID-19 infection. Angiographic and procedural findings indicating successful reperfusion were better in patients without a history of COVID-19. A history of COVID-19 infection (odds ratio 1.40, 95% confidence interval 1.25-1.60, P < .01) independently predicted MACE. A history of COVID-19 infection is a predictor of worse outcomes following coronary intervention and in-hospital MACE among patients with STEMI.

Acute Response of the Noninfarcted Myocardium and Surrounding Tissue Assessed by T2 Mapping After STEMI

BACKGROUND

ST-segment elevation myocardial infarction (STEMI) is associated with a systemic and local inflammatory response with edema. However, their role at the tissue level is poorly characterized.

OBJECTIVES

This study aims to characterize T2 values of the noninfarcted myocardium (NIM) and surrounding tissue and to investigate prognostic relevance of higher NIM T2 values after STEMI.

METHODS

A total of 171 consecutive patients with STEMI without prior cardiovascular events who underwent cardiac magnetic resonance after primary percutaneous coronary intervention were analyzed in terms of standard infarct characteristics. Edema of the NIM, liver, spleen, and pectoralis muscle was assessed based on T2 mapping. Follow-up was available for 130 patients. The primary endpoint was major adverse cardiac events (MACE), defined as cardiovascular death, myocardial infarction, unplanned coronary revascularization or rehospitalization for heart failure. The median time from primary percutaneous coronary intervention to cardiac magnetic resonance was 3 days (IQR: 2-5 days).

RESULTS

Higher (above the median value of 45 ms) T2 values in the NIM area were associated with larger infarct size, microvascular obstruction, and left ventricular dysfunction and did not correlate with C-reactive protein, white blood cells, or T2 values of the pectoralis muscle, liver, and spleen. At a median follow-up of 17 months, patients with higher (>45 ms) NIM T2 values had increased risk of MACE (P < 0.001) compared with subjects with NIM T2 values ≤45 ms, mainly caused by a higher rate of myocardial reinfarction (26.3% vs 1.4%; P < 0.001). At multivariable analysis, higher NIM T2 values independently predicted MACE (HR: 2.824 [95% CI: 1.254-6.361]; P = 0.012).

CONCLUSIONS

Higher NIM T2 values after STEMI are independently associated with worse cardiovascular outcomes, mainly because of higher risk of myocardial infarction.

Relationship between systemic immune inflammation index and development of complete atrioventricular block in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention

BACKGROUND

The systemic immune-inflammation index (SII), based on white blood cell, neutrophil, and platelet counts, is a proposed marker of systemic inflammation and immune activation. This study aimed to explore the relationship between SII and complete atrioventricular block (CAVB) development in STEMI patients undergoing primary PCI.

METHODS

We retrospectively analyzed data from 883 patients who underwent primary PCI for STEMI between January 2009 and December 2017. Patients were categorized into two groups based on CAVB development. SII levels were calculated from blood samples taken on admission.

RESULTS

Of the included patients, 48 (5.03%) developed CAVB. SII was higher in patients with CAVB compared to those without CAVB (1370 [1050-1779]x109/L vs. 771 [427-1462] x109/L, p < 0.001). Multivariate analysis showed a significant positive correlation between SII and the risk of CAVB development (OR:1.0003, 95%CI:1.0001-1.0005, P = 0.044). The cut-off value for the SII in the estimation of CAVB was 1117.7 × 109/L (area under the ROC curve [AUC]: 0.714, 95% CI = 0.657-0.770 with a sensitivity of 70.8% and specificity of 65.6%, p < 0.001).

CONCLUSION

This study showed a significant link between high SII levels and CAVB development in STEMI patients undergoing PCI. Our findings suggest that SII may be a valuable, routinely available, and inexpensive marker for identifying patients at increased risk of CAVB.

The prognostic value of dynamic changes in SII for the patients with STEMI undergoing PPCI

BACKGROUND

Predicting the prognosis of primary percutaneous coronary intervention(PPCI) in ST-segment elevation myocardial infarction (STEMI) patients in the perioperative period is of great clinical significance. The inflammatory response during the perioperative period is also an important factor. This study aimed to investigate the dynamic changes in the systemic immune inflammatory index (SII) during the perioperative period of PPCI and evaluate its predictive value for in-hospital and out-of-hospital outcomes in patients with STEMI.

METHODS

This retrospective study included 324 consecutive patients with STEMI who were admitted to the cardiac care unit. Blood samples were collected before PPCI, 12 h (T1), 24 h, 48 h after PPCI, the last time before hospital discharge (T2), and 1 month after hospital discharge. The SII was calculated as (neutrophils×platelets)/lymphocytes. Based on whether the primary endpoint occurred, we divided the patients into event and non-event groups. Univariate and multivariate logistic regression analyses were performed to identify independent risk factors that might influence the occurrence of the primary endpoint. Dynamic curves of SII were plotted, and receiver operating characteristic (ROC) curves were drawn for each node to calculate the optimal critical value, sensitivity, and specificity to assess their predictive ability for in-hospital and out-of-hospital courses. Kaplan-Meier curves were used to analyze the differences in survival rates at different SII inflammation levels.

RESULTS

High levels of SII were individually related to the occurrence of the in-hospital period and long-term outcomes during the post-operative follow-up of STEMI patients (in-hospital SII: T1:OR 1.001,95%CI 1.001-1.001, P < 0.001; SII following hospital discharge: T1M: OR 1.008,95%CI 1.006-1.010, P < 0.001). Patients with high SII levels had lower survival rates than those with low SII levels. The analysis showed that the SII 12 h after (T1) and SII 1 month (T1M) had excellent predictive values for the occurrence of in-hospital and out-of-hospital outcomes, respectively (AUC:0.896, P < 0.001; AUC:0.892, P < 0.001).

CONCLUSION

There is a significant relationship between the dynamic status of SII and prognosis in patients with STEMI. This study found that the 12 h and SII 1 month affected in-hospital and out-of-hospital outcomes, respectively. Consequently, we focused on the dynamic changes in the SII.

Association of dysglycaemia with persistent infarct core iron in patients with acute ST-segment elevation myocardial infarction

BACKGROUND

Dysglycaemia increases the risk of myocardial infarction and subsequent recurrent cardiovascular events. However, the role of dysglycaemia in ischemia/reperfusion injury with development of irreversible myocardial tissue alterations remains poorly understood. In this study we aimed to investigate the association of ongoing dysglycaemia with persistence of infarct core iron and their longitudinal changes over time in patients undergoing primary percutaneous coronary intervention (PCI) for acute ST-segment elevation myocardial infarction (STEMI).

METHODS

We analyzed 348 STEMI patients treated with primary PCI between 2016 and 2021 that were included in the prospective MARINA-STEMI study (NCT04113356). Peripheral venous blood samples for glucose and glycated hemoglobin (HbA1c) measurements were drawn on admission and 4 months after STEMI. Cardiac magnetic resonance (CMR) imaging including T2 * mapping for infarct core iron assessment was performed at both time points. Associations of dysglycaemia with persistent infarct core iron and iron resolution at 4 months were calculated using multivariable regression analysis.

RESULTS

Intramyocardial hemorrhage was observed in 147 (42%) patients at baseline. Of these, 89 (61%) had persistent infarct core iron 4 months after infarction with increasing rates across HbA1c levels (<5.7%: 33%, ≥5.7: 79%). Persistent infarct core iron was independently associated with ongoing dysglycaemia defined by HbA1c at 4 months (OR: 7.87 [95% CI: 2.60-23.78]; p < 0.001), after adjustment for patient characteristics and CMR parameters. The independent association was present even after exclusion of patients with diabetes (pre- and newly diagnosed, n = 16).

CONCLUSIONS

In STEMI patients treated with primary PCI, ongoing dysglycaemia defined by HbA1c is independently associated with persistent infarct core iron and a lower likelihood of iron resolution. These findings suggest a potential association between ongoing dysglycaemia and persistent infarct core iron, which warrants further investigation for therapeutic implications.

HbA1c/C-Peptide Ratio Is a Potential Biomarker Used to Predict No-Reflow Phenomenon in Patients With ST-Elevation Myocardial Infarction

In this letter, we discussed that HbA1c/C-peptide ratio is a potential biomarker used to predict no-reflow phenomenon in patients with ST-elevation myocardial infarction.

Factors of Hospital Mortality in Men and Women with ST-Elevation Myocardial Infarction - An Observational, Retrospective, Single Centre Study

Purpose

There are well-known gender differences in mortality of patients with ST-elevation myocardial infarction (STEMI). Our purpose was to assess factors of hospital mortality separately for men and women with STEMI, which are less well known.

Patients and Methods

In 2018-2019, 485 men and 214 women with STEMI underwent treatment with primary percutaneous coronary intervention (PCI). We retrospectively compared baseline characteristics, treatments and hospital complications between men and women, as well as between nonsurviving and surviving men and women with STEMI.

Results

Primary PCI was performed in 94% of men and 91.1% of women with STEMI, respectively. The in-hospital mortality was significantly higher in women than in men (14% vs 8%, p=0.019). Hospital mortality in both genders was associated significantly to older age, heart failure, prior resuscitation, acute kidney injury, to less likely performed and less successful primary PCI and additionally in men to hospital infection and in women to bleeding. In men and women ≥65 years, mortality was similar (13.3% vs 17.8%, p = 0.293).

Conclusion

Factors of hospital mortality were similar in men and women with STEMI, except bleeding was more likely observed in nonsurviving women and infection in nonsurviving men.

Cardiac magnetic resonance for the early prediction of reverse left ventricular remodeling in patients with ST-segment elevation myocardial infarction

OBJECTIVES

To evaluate the changes in cardiac magnetic resonance (CMR) characteristics and investigate the predictors of reverse left ventricular remodeling (r-LVR) in ST-segment elevation myocardial infarction (STEMI) patients.

MATERIALS AND METHODS

Eighty-six STEMI patients (median 56 years) were retrospectively studied. The patients were divided into r-LVR and without r-LVR groups. CMR analysis included LV volume, infarct characteristics, and global and regional myocardial function. The strain and displacement were assessed by CMR-feature tracking. The predictors of r-LVR were analyzed by the logistic regression method.

RESULTS

There were 37 patients in the r-LVR group and 49 patients in the without r-LVR group. At initial CMR, there was no difference in LV volume and global cardiac function between the two groups. However, the infarct zone radial and longitudinal displacements were higher in the r-LVR group (p < 0.05, respectively). At the second CMR, the r-LVR group showed higher LVEF, lower LV volume, and total enhanced mass (all p < 0.05). The infarct zone radial and circumferential strains and radial displacement were higher in the r-LVR group (all p < 0.05). The r-LVR group had better recovery of myocardial injury and function. Of note, microvascular obstruction (MVO) mass (odds ratio: 0.779 (0.613-0.989), p = 0.041) and infarct zone peak longitudinal displacement (PLD) (odds ratio: 1.448 (1.044-2.008), p = 0.026) were independent predictors of r-LVR.

CONCLUSIONS

At initial CMR, there were no differences in global cardiac function between the two groups, but infarct zone displacements were higher in the r-LVR group. The r-LVR group had better recovery of cardiac function. In addition, MVO mass and infarct zone PLD were independent predictors of r-LVR.

CLINICAL RELEVANCE STATEMENT

Our study assessed changes in cardiac structure, function, and tissue characteristics after STEMI by CMR, investigated the best predictors of r-LVR in STEMI patients, and laid the foundation for the development of new parameter-guided treatment strategies for STEMI patients.

KEY POINTS

• At initial CMR, the reverse left ventricular remodeling (r-LVR) group had less myocardial damage and higher infarct zone displacement, but there were no differences in global function between the two groups. • Both groups showed recovery of myocardial injury and cardiac function over time, but the r-LVR group had less enhanced mass and better cardiac function compared to the without r-LVR group at the second CMR. • Microvascular obstruction mass and infarct zone peak longitudinal displacement by cardiac magnetic resonance feature-tracking were significant predictors of r-LVR in STEMI patients.

STEMI in women. Life expectancy recovery after primary percutaneous coronary intervention

INTRODUCTION AND OBJECTIVES

Despite medical advances, mortality after ST-elevation myocardial infarction (STEMI) remains high. Women are often underrepresented in trials and registries, limiting knowledge of their management and prognosis. It is unknown whether life expectancy in women of all ages treated with primary percutaneous coronary intervention (PPCI) is similar to that in a reference population free of the disease. The main objective of this study was to determine whether life expectancy in women undergoing PPCI and surviving the main event returns to a similar level to that in the general population of the same age and region.

METHODS

We included all patients diagnosed with STEMI from January 2014 to October 2021. We matched women to a reference population of the same age and region from the National Institute of Statistics to determine observed survival, expected survival, and excess mortality (EM) using the Ederer II method. We repeated the analysis in women aged ≤ 65 and> 65 years.

RESULTS

A total of 2194 patients were recruited, of whom 528 were women (23.9%). In women surviving the first 30 days, EM at 1, 5 and 7 years was 1.6% (95%CI, 0.3-4), 4.7% (95%CI, 0.3-10.1), and 7.2% (95%CI, 0.5-15.1), respectively.

CONCLUSIONS

EM was reduced in women with STEMI who were treated with PPCI and who survived the main event. However, life expectancy remained lower than that in a reference population of the same age and region.

Survivorship With Incrementally Faster Times to Primary Percutaneous Coronary Intervention (SWIFT-PPCI): A Systematic Review and Meta-Analysis

In the United States, there are approximately 750,000 ST-elevation myocardial infarction cases each year. Streamlined care and rapid delivery for primary percutaneous coronary intervention (PPCI) is associated with improved survival. This systematic review and meta-analysis aimed to generate a practical estimate of mortality savings for every notional 30-minute decrease in the time to achieving PPCI. Included studies were those that provided a specific absolute risk reduction for a specific reduction in pre-PPCI time. The eligible studies evaluated the survival benefit from pre-PPCI time savings measured in any interval ending with PPCI and commencing with objectively recorded timing, such as initial emergency call, first medical contact, or hospital arrival. Study planning called for the reporting of data as individual study results, with a pooled effect estimate of relative risk calculated with random-effects meta-analysis. A total of 1,088 records were eligible for review; 52 were reviewed in full text, with 4 studies (total patient n = 235,814, overall mortality 4.7% to 7.8%) included in the final analysis. All 4 studies reported significant time-related survival benefit over the study focus window of 60 to 180 minutes pre-PPCI. The number of lives saved per 100 cases for each 30-minute pre-PPCI time savings ranged from 0.8 to 1.9. The overall effect estimate generated was 0.753 (95% confidence interval 0.712 to 0.796), with acceptable heterogeneity (I2 = 36%). In conclusion, a pooled effect calculation estimated a 24.7% relative risk reduction for each 30 minutes of time savings. For cases that underwent PPCI within 60 to 180 minutes of initial presentation with known baseline mortality risk, the time savings in 30-minute epochs can be leveraged to estimate a specific number of lives saved; this may be useful for those involved in the organization of medical care who make systemwide plans and individual patient triage decisions.

Impact of Excessive Increase in Systolic Blood Pressure after Exercise on Clinical Outcomes in Patients with ST-Segment Elevation Myocardial Infarction

OBJECTIVE

Although the clinical outcomes for patients with ST-elevation myocardial infarction (STEMI) have improved significantly, some patients still experience poor clinical outcomes. The available risk classifications focus on the short-term outcomes, and it remains important to find high-risk features among patients with STEMI. In Japan, the 200 m walk electrocardiogram (ECG) test is widely performed before discharge. The purpose of this study was to investigate the association between the excessive increase in systolic blood pressure (SBP) following a 200 m walk and the long-term clinical outcomes in patients with STEMI.

METHODS

We included 680 patients with STEMI and divided those into an excessive increase in SBP group (n = 144) and a non-excessive increase in SBP group (n = 536) according to the SBP increase after a 200 m walk ECG test. We defined an excessive increase in SBP as SBP ≥ 20 mmHg either just after or 3 min after a 200 m walk ECG test. The primary endpoint consisted of major cardiovascular events (MACE), defined as the composite of all-cause death, non-fatal myocardial infarction, readmission for heart failure, and ischemia-driven target vessel revascularization.

RESULTS

The median follow-up duration was 831 days. MACE was more frequently observed in the excessive increase in SBP group (24.3%) than in the non-excessive increase in SBP group (15.1%). Multivariate Cox hazard analysis revealed that the excessive increase in SBP was significantly associated with MACE (HR 1.509, 95% CI: 1.005-2.267, p = 0.047) after controlling for multiple confounding factors.

CONCLUSION

An excessive increase in SBP after the 200 m walk ECG test was significantly associated with MACE in patients with STEMI. The 200 m walk ECG test is simple and low-cost, but may help to identify high-risk patients with STEMI.

The HbA1c/C-Peptide Ratio is Associated With the No-Reflow Phenomenon in Patients With ST-Elevation Myocardial Infarction

Currently, the gold standard treatment for ST-elevation myocardial infarction (STEMI) is primary percutaneous coronary intervention (pPCI), but even after successful pPCI, a perfusion disorder in the epicardial coronary arteries, termed no-reflow phenomenon (NR), can develop, resulting in short- and long-term adverse events. The present study assessed the relationship between NR and HbA1c/C-peptide ratio (HCR) in 1834 consecutive patients who underwent pPCI due to STEMI. Participants were divided into two groups according to NR status and the demographic, clinical and periprocedural characteristics of the groups were compared. NR developed in 352 (19.1%) of the patients in the study. While C-peptide levels were significantly lower in the NR group, HbA1c and HCR were significantly higher (P < .001, for all). In multivariable analysis, C-peptide, HbA1c, and HCR, were determined as independent predictors for NR (P < .05, for all). In Receiver Operating Characteristic (ROC) analysis, HCR predicted the NR with 80% specificity and 77% sensitivity. In STEMI patients, combining HbA1c and C-peptide in a single fraction has a predictive value for NR independent of diabetes. This ratio may contribute to risk stratification of STEMI patients.

Meteorin-like protein is associated with a higher risk profile and predicts a worse outcome in patients with STEMI

INTRODUCTION AND OBJECTIVES

Meteorin-like protein (Metrnl) is a cytokine involved in the attenuation of inflammation. In patients with heart failure, high levels of this biomarker are associated with a worse outcome. In this study, we evaluated the circulating levels and prognostic value of Metrnl in patients with ST-segment elevation myocardial infarction (STEMI).

METHODS

We enrolled STEMI patients undergoing primary percutaneous coronary intervention. Circulating Metrnl levels were measured in peripheral blood 12hours after symptom onset. The primary endpoint was a composite of all-cause mortality or nonfatal myocardial infarction (MI) at 3 years.

RESULTS

We studied 381 patients (mean age 61 years, 21% female, 8% Killip class III/IV). Metrnl levels were associated with age, cardiovascular risk factors and the extent of coronary artery disease, as well as with STEMI complications, particularly heart failure and cardiogenic shock. Multivariable Cox regression analysis revealed that Metrnl independently predicted all-cause death or nonfatal MI at 3 years (HR, 1.86; 95%CI, 1.23-2.81; P=.003). Moreover, patients in the highest tertile (> 491.6 pg/mL) were at higher risk for the composite endpoint than those in the lowest tertiles (HR, 3.24; 95%CI, 1.92-5.44; P <.001), even after adjustment by age, diabetes mellitus, cardiac arrest, Killip-Kimball III/IV class, left ventricular ejection fraction, and creatinine clearance (HR, 1.90; 95%CI, 1.10-3.29; P=.021).

CONCLUSIONS

Circulating Metrnl levels are associated with complications during the acute phase of STEMI and independently predict a worse outcome in these patients.

Identification of acute ST-elevation myocardial infarction via remote implantable loop recorder monitor

The indications for the use of implantable loop recorders include the evaluation of unexplained palpitations and syncope, embolic stroke of undetermined source, dizziness and lightheadedness presumed to be due to arrhythmogenic etiology, and for atrial fibrillation to guide antiarrhythmic drug therapy or catheter ablation efficacy. Long-term monitoring is especially beneficial if symptoms occur sporadically or are asymptomatic in nature. This is the first case to our knowledge of an acute ST-elevation myocardial infarction which was identified from remote monitoring of an implantable loop recorder through a device clinic.

Improved detection of echocardiographically occult left ventricular thrombi following ST-elevation myocardial infarction

AIM

The aim of this study was to investigate predictors of transthoracic echocardiography (TTE)-occult left ventricular (LV) thrombi (LVT) and to propose a clinical model for improved detection of TTE-occult LVT post-ST-elevation myocardial infarction (STEMI). Patients with acute STEMI are at significant risk for developing LVT. However, this complication often (up to 65%) remains undetected by using TTE, referred to as TTE-occult LVT.

METHODS AND RESULTS

In total, 870 STEMI patients underwent TTE and cardiac magnetic resonance (CMR), the reference method for LVT detection, 3 days after infarction. Clinical (body mass index, peak cardiac troponin T) and echocardiographic [ejection fraction, apical wall motion scores (AWMSs)] predictors were analysed. Primary endpoint was the presence of TTE-occult LVT identified by CMR imaging. From the overall cohort, 37 patients (4%) showed an LVT by CMR. Of these thrombi, 25 (68%) were not identified by TTE. Transthoracic echocardiography-occult thrombi did not significantly differ in volume (1.4 vs. 2.74 cm3), diameter (19.0 vs. 23.3 mm), and number of fragments or shape compared with TTE-apparent LVT (all P > 0.05). For predicting these TTE-occult LVT, the 16-segment AWMS (AWMS16Seg) showed highest validity {area under the curve: 0.91 [95% confidence interval (CI): 0.89-0.93]; P < 0.001}, with an association independent of ejection fraction and 17-segment AWMS (AWMS17Seg) [odds ratio: 1.68 (95% CI: 1.43-1.97); P < 0.001] and clinical (body mass index, peak troponin) and angiographic (culprit lesion, post-interventional thrombolysis in myocardial infarction flow) associates of TTE-occult LVT (all P < 0.05). Dichotomization at AWMS16Seg ≥ 8 (n = 260, 30%) allowed for a detection of all TTE-occult LVT (sensitivity: 100%), with a corresponding specificity of 77%.

CONCLUSION

After acute STEMI, AWMS16Seg served as a simple and very robust predictor of TTE-occult LVT. An AWMS16Seg-based algorithm to identify patients for additional CMR imaging offers great potential to optimize detection of TTE-occult LVT following STEMI.

Analysis of immortal-time effect in post-infarction ventricular septal defect

Introduction

Time-fixed analyses have traditionally been utilized to examine outcomes in post-infarction ventricular septal defect (VSD). The aims of this study were to: (1) analyze the relationship between VSD closure/non-closure and mortality; (2) assess the presence of immortal-time bias.

Material and methods

In this retrospective cohort study, patients with ST-elevation myocardial infarction (STEMI) complicated by VSD. Time-fixed and time-dependent Cox regression methodologies were employed.

Results

The study included 80 patients: surgical closure (n = 26), transcatheter closure (n = 20), or conservative management alone (n = 34). At presentation, patients without VSD closure exhibited high-risk clinical characteristics, had the shortest median time intervals from STEMI onset to VSD development (4.0, 4.0, and 2.0 days, respectively; P = 0.03) and from STEMI symptom onset to hospital arrival (6.0, 5.0, and 0.8 days, respectively; P < 0.0001). The median time from STEMI onset to closure was 22.0 days (P = 0.14). In-hospital mortality rate was higher among patients who did not undergo defect closure (50%, 35%, and 88.2%, respectively; P < 0.0001). Closure of the defect using a fixed-time method was associated with lower in-hospital mortality (HR = 0.13, 95% CI 0.05-0.31, P < 0.0001, and HR 0.13, 95% CI 0.04-0.36, P < 0.0001, for surgery and transcatheter closure, respectively). However, when employing a time-varying method, this association was not observed (HR = 0.95, 95% CI 0.45-1.98, P = 0.90, and HR 0.88, 95% CI 0.41-1.87, P = 0.74, for surgery and transcatheter closure, respectively). These findings suggest the presence of an immortal-time bias.

Conclusions

This study highlights that using a fixed-time analytic approach in post-infarction VSD can result in immortal-time bias. Researchers should consider employing time-dependent methodologies.

Validation of ICD-10-CM Diagnostic Codes for Identifying Patients with ST-Elevation and Non-ST-Elevation Myocardial Infarction in a National Health Insurance Claims Database

Purpose

Distinguishing ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) is crucial in acute myocardial infarction (AMI) research due to their distinct characteristics. However, the accuracy of International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes for STEMI and NSTEMI in Taiwan's National Health Insurance (NHI) database remains unvalidated. Therefore, we developed and validated case definition algorithms for STEMI and NSTEMI using ICD-10-CM and NHI billing codes.

Patients and Methods

We obtained claims data and medical records of inpatient visits from 2016 to 2021 from the hospital's research-based database. Potential STEMI and NSTEMI cases were identified using diagnostic codes, keywords, and procedure codes associated with AMI. Chart reviews were then conducted to confirm the cases. The performance of the developed algorithms for STEMI and NSTEMI was assessed and subsequently externally validated.

Results

The algorithm that defined STEMI as any STEMI ICD code in the first three diagnosis fields had the highest performance, with a sensitivity of 93.6% (95% confidence interval [CI], 91.7-95.2%), a positive predictive value (PPV) of 89.4% (95% CI, 87.1-91.4%), and a kappa of 0.914 (95% CI, 0.900-0.928). The algorithm that used the NSTEMI ICD code listed in any diagnosis field performed best in identifying NSTEMI, with a sensitivity of 82.6% (95% CI, 80.7-84.4%), a PPV of 96.5% (95% CI, 95.4-97.4), and a kappa of 0.889 (95% CI, 0.878-0.901). The algorithm that included either STEMI or NSTEMI ICD codes listed in any diagnosis field showed excellent performance in defining AMI, with a sensitivity of 89.4% (95% CI, 88.2-90.6%), a PPV of 95.6% (95% CI, 94.7-96.4%), and a kappa of 0.923 (95% CI, 0.915-0.931). External validation confirmed these algorithms' efficacy.

Conclusion

Our results provide valuable reference algorithms for identifying STEMI and NSTEMI cases in Taiwan's NHI database.

Strategy of dual antiplatelet therapy for patients with ST-elevation myocardial infarction and non-ST-elevation acute coronary syndromes: A systematic review and network meta-analysis

BACKGROUND

Various durations and de-escalation strategies of dual antiplatelet therapy (DAPT) after ST-elevation myocardial infarction (STEMI) or non-ST-elevation acute coronary syndromes (NSTE-ACS) have been tested in randomized controlled trials (RCT)s. However, evidence by specific ACS subtype is unknown.

METHODS

PubMed, EMBASE, and Cochrane CENTRAL were searched in February 2023. RCTs on DAPT strategies included STEMI or NSTE-ACS patients with standard DAPT (12 months) with clopidogrel or potent P2Y12 inhibitors, short-term DAPT (≤6 months) followed by potent P2Y12 inhibitors or aspirin, unguided de-escalation from potent P2Y12 inhibitors to low-dose potent P2Y12 inhibitors or clopidogrel at one month, and guided selection with genotype or platelet function tests were identified. The primary outcome was the net adverse clinical events (NACE) defined as a composite of major adverse cardiovascular events (MACE) and clinically relevant bleeding events.

RESULTS

Twenty RCTs with a combined total population of 24,745 STEMI and 37,891 NSTE-ACS patients were included. In STEMI patients, unguided de-escalation strategy was associated with a lower rate of NACE compared with standard DAPT using potent P2Y12 inhibitors (HR:0.57; 95% CI:0.34-0.96) without increased risk of MACE. In NSTE-ACS patients, unguided de-escalation strategy was associated with a lower rate of NACE compared with the guided selection strategy (HR:0.65; 95% CI:0.47-0.90), standard DAPT using potent P2Y12 inhibitors (HR:0.62; 95% CI:0.50-0.78) and standard DAPT using clopidogrel (HR:0.73; 95% CI:0.55-0.98) without increased risk of MACE.

CONCLUSION

Unguided de-escalation strategy was associated with a reduced risk of NACE and may be the most effective DAPT strategy for STEMI and NSTE-ACS.

Left ventricular dyssynchrony measured by cardiovascular magnetic resonance-feature tracking in anterior ST-elevation myocardial infarction: relationship with microvascular occlusion myocardial damage

Objectives

Cardiovascular magnetic resonance-feature tracking (CMR-FT) enables quantification of myocardial deformation and may be used as an objective measure of myocardial involvement in ST-elevation myocardial infarction (STEMI). We sought to investigate the associations between myocardial dyssynchrony parameters and myocardium damage for STEMI.

Methods

We analyzed 65 patients (45-80 years old) with anterior STEMI after primary percutaneous coronary intervention during 3-7 days [observational (STEMI) group] and 60 healthy volunteers [normal control (NC) group]. Myocardial dyssynchrony parameters were derived, including global and regional strain, radial rebound stretch and displacement, systolic septal time delay, and circumferential stretch.

Results

CMR characteristics, including morphologic parameters such as left ventricular ejection fraction (LVEF) (45.3% ± 8.2%) and myocardium damage in late gadolinium enhancement (LGE) (19.4% ± 4.7% LV), were assessed in the observation group. The global radial strain (GRS) and global longitudinal strain (GLS) substantially decreased in anterior STEMI compared with the NC group (GRS: 19.4% ± 5.1% vs. 24.8% ± 4.0%, P < 0.05; GLS: -10.1% ± 1.7% vs. -13.7% ± 1.0%, P < 0.05). Among 362 infarcted segments, radial and circumferential peak strains of the infarcted zone were the lowest (14.4% ± 3.2% and -10.7% ± 1.6%, respectively). The radial peak displacement of the infarct zone significantly decreased (2.6 ± 0.4 mm) (P < 0.001) and manifested in the circumferential displacement (3.5° ± 0.7°) in the STEMI group (P < 0.01). As microvascular occlusion (MVO) was additionally present, some strain parameters were significantly impaired in LGE+/MVO+ segments (radial strain [RS]: 12.2% ± 2.1%, circumferential strain [CS]: -9.6% ± 0.7%, longitudinal strain [LS]: -6.8% ± 1.0%) compared to LGE+/MVO- (RS: 14.6% ± 3.2%, CS: -10.8% ± 1.8%, LS: -9.2% ± 1.3%) (P < 0.05). When the extent of transmural myocardial infarction is greater than 75%, the parameter of the systolic septal delay (mean, 148 ms) was significantly reduced compared to fewer degrees of infarction (P < 0.01).

Conclusion

In anterior STEMI, the infarcted septum swings in a bimodal mode, and myocardial injury reduces the radial strain contractility. A more than 75% transmural degree was the septal strain-contraction reserve cut-off point.

Coronary Artery Bypass Graft Surgery After Primary Percutaneous Coronary Intervention in Patients With ST-Elevation Myocardial Infarction

OBJECTIVE

To determine whether primary percutaneous coronary intervention (PPCI) is associated with adverse outcomes following coronary artery bypass graft (CABG) among patients with ST-elevation myocardial infarction (STEMI).

METHODS

Patients presenting with acute STEMI who underwent CABG between September 2015 and November 2020 were included. Among 354 patients, 222 (62.7%) underwent PPCI prior to CABG (PPCI+CABG group) and were compared with the rest of the patients (CABG only group). The effects of PPCI on primary endpoints---including in-hospital mortality, length of stay (LOS), and bleeding events---were investigated using the stabilised inverse probability weighting method (S-IPW). Further, in-hospital mortality in various PPCI subgroups was analysed using univariable regression.

RESULTS

Patients with and without PPCI were comparable regarding their baseline and surgical characteristics, except that those without PPCI were more likely to have left-main disease (29.5% vs 16.2%, p-value=0.003). Among the PPCI+CABG group, 3.6% mortality and 55.9% bleeding events occurred, and the LOS was 7 [5-10] days. The respective figures for the CABG only group were 4.5%, 50.8%, and 7 [6-10.5] days. Primary percutaneous coronary intervention, as a whole, was not significantly associated with either morality (S-IPW odds ratio (S-IPW OR) 0.61; p=0.393), LOS logarithm (S-IPW β -0.050; p=0.403), or bleeding events (S-IPW OR 1.06; p=0.821). Nevertheless, the unadjusted mortality risk was significantly higher in complicated PPCIs compared with the CABG only group (OR 7.50, 95% CI 2.03-27.77); it was also higher among some other PPCI subgroups, albeit non-significantly.

CONCLUSION

This study found that PPCI did not confer additional risk regarding in-hospital mortality, LOS, or bleeding among patients with acute STEMI who underwent CABG. However, some PPCI subgroups, especially those with complicated PPCI, were at increased risk.

Short and Long-Term Prognostic Significance of Galectin-3 in Patients with ST-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

This study evaluated the short and long-term prognostic value of galectin-3 in patients with ST-segment elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (PCI). Patients (n = 143) were admitted with STEMI and followed up for 2 years. The study population was divided into high and low galectin-3 groups based on the admission median value of serum galectin-3. Primary clinical outcomes consisted of cardiovascular (CV) mortality, non-fatal reinfarction, stroke, and target vessel revascularization (TVR). CV events were recorded in hospital and at 1 and 2 years. The primary clinical outcomes (in-hospital, 1 year and 2 year) were significantly higher in the high galectin-3 group. (P = .008, P = .004, P = .002, respectively). High galectin-3 levels were also associated with heart failure development and re-hospitalization at both 1 year (P = .029, P = .009, respectively) and 2 years (P = .019, P = .036, respectively). According to Cox multivariate analysis, left ventricular ejection fraction (LVEF) was an independent predictor of 2-year cardiovascular mortality (P = .009), whereas galectin-3 was not (P = .291). Although high galectin-3 levels were not independent predictors of long-term CV mortality in patients with acute STEMI who underwent primary PCI, it was associated with short-term and long-term development of adverse CV events, heart failure, and re-hospitalization.

Racial disparities in women with ST elevation myocardial infarction: A National Inpatient Sample review of baseline characteristics, co-morbidities, and outcomes in women with STEMI

BACKGROUND

A third of the patients admitted with Acute coronary syndrome (ACS) have ST-elevation myocardial infarction (STEMI). Previous studies showed that females with STEMI have higher mortality than men.

HYPOTHESIS

There exist significant disparities in outcomes among women of different races presenting with STEMI.

METHODS

National inpatient sample (NIS) data was obtained from January 2016 to December 2018 for the hospitalization of female patients with STEMI. We compared outcomes, using an extensive multivariate regression analysis amongst women from different races. Our primary outcome was in-hospital mortality. Secondary outcomes were revascularization use, procedure complications, and healthcare utilization.

RESULTS

Of 202 223 female patients with STEMI; 11.3% were African American, 7.4% Hispanic, 2.4% Asian, and 4.3% another race. In-hospital mortality was higher in non-Caucasian groups. African American (adjusted odds ratio [aOR] 1.2; 95% confidence interval [CI]: 1.07-1.30; p < .01) and another race (aOR 1.37; 95% CI: 1.15-1.63; p < .01) had higher odds of mortality when compared with white women. African American (aOR 0.69; 95% CI: 0.62-0.72; p < .01), Hispanics (aOR 0.81; 95% CI: 0.74-0.88; p < .01), and Asian (aOR 0.79; 95% CI: 0.69-0.90; p < .01) had lower odds of percutaneous intervention (PCI) when compared with whites. African Americans had fewer odds of Coronary Artery Bypass Graft (CABG) and use of Mechanical Circulatory Support (MCS) during the index admission. Non-Caucasians had more comorbidities, complications, and healthcare utilization costs.

CONCLUSION

There are significant racial disparities in clinical outcomes and revascularization in female patients with STEMI. African American women have a higher likelihood of mortality among the different races. Females from minority groups are also less likely to undergo PCI.

Unveiling the Influence of Smoking and Uncontrolled Lipid Profile in the Development of ST-Elevation Myocardial Infarction

We report a case of a 25-year-old male with the traditional risk factor for coronary artery disease (CAD), such as frequent smoking, while the other risk factors such as familial history of CAD were denied and hypertension, obesity, diabetes mellitus, or coagulation factors were not found. Patient was admitted with anterior ST-elevation myocardial infarction. Coronary angiography showed high intracoronary thrombus burden and total occlusion of the proximal segment of left anterior descending artery. Percutaneous coronary intervention was then performed as the treatment of choice, and resulted with no residual stenosis after. The patient had a smooth and progressive recovery.

Optical Coherence Tomography-Guided Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction: Rationale and Design of the ATLAS-OCT Study

Even after successful revascularization with primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI), subsequent adverse events still occur. Previous studies have suggested potential benefits of intravascular imaging, including optical coherence tomography (OCT). However, the feasibility of OCT-guided primary PCI has not been systematically examined in these patients. The ATLAS-OCT (ST-elevation Acute myocardial infarcTion and cLinicAl outcomeS treated by Optical Coherence Tomography-guided percutaneous coronary intervention) trial was designed to investigate the feasibility of OCT guidance during primary PCI for STEMI in experienced centers with expertise on OCT-guided PCI as a prospective, multicenter registry of consecutive patients with STEMI who underwent a primary PCI. The sites' inclusion criteria are as follows: (1) acute care hospitals providing 24/7 emergency care for STEMI, and (2) institutions where OCT-guided PCI is the first choice for primary PCI in STEMI. All patients with STEMI who underwent primary PCI at participating sites will be consecutively enrolled, irrespective of OCT use during PCI. The primary end point will be the rate of successful OCT imaging during the primary PCI. As an ancillary imaging modality to angiography, OCT provides morphologic information during PCI for the assessment of plaque phenotypes, vessel sizing, and PCI optimization. Major adverse cardiac events, defined as a composite of all-cause death, myocardial infarction, and target vessel revascularization at 1 year, will also be recorded. The ATLAS-OCT study will clarify the feasibility of OCT-guided primary PCI for patients with STEMI and further identify a suitable patient group for OCT-guided primary PCI.

Comparative Evaluation of Intermountain Risk Score With Mehran Risk Score for Risk Estimation of Contrast-Induced Nephropathy and Short-Term Mortality in ST-Segment Elevation Myocardial Infarction Patients

Contrast-induced nephropathy (CIN) has become one of the most important causes of in-hospital acute renal failure with the increasing use of contrast-mediated imaging tools. This significantly increases the morbidity and mortality of the affected subjects and causes a financial burden on the health system. In this context, prediction of CIN is important and some risk scores have been developed to predict CIN. The most frequently used and popular among these is the Mehran Score (MS), which is based on a number of hemodynamic and metabolic parameters. The Intermountain Risk Score (IMRS) is a recently developed risk score that highly predicts short-term mortality based on common laboratory parameters, and many parameters of this risk score have been found to be closely associated with CIN. In this context, we aimed to compare MS and IMRS in terms of CIN and short-term mortality estimation. The study included 931 patients who underwent percutaneous coronary intervention. CIN developed in 21.5% of patients. Both MS and IMRS independently predicted CIN. In receiver operating characteristic analysis, IMRS was found to be non-inferior to MS in predicting CIN and IMRS was superior to MS in predicting short-term mortality. IMRS and MS were independently associated with short-term mortality.

Intensive lipid-lowering therapy for early achievement of guideline-recommended LDL-cholesterol levels in patients with ST-elevation myocardial infarction ("Jena auf Ziel")

BACKGROUND AND AIMS

Currently, less than 20% of patients at very high-risk achieve ESC/EAS dyslipidemia guideline-recommended LDL-C target levels in Europe. "Jena auf Ziel-JaZ" is a prospective cohort study in which early combination therapy with atorvastatin 80 mg and ezetimibe 10 mg was initiated on admission in patients with ST-elevation myocardial infarction (STEMI) and lipid-lowering therapy was escalated during follow-up with bempedoic acid and PCSK9 inhibitors to achieve recommended LDL-C targets in all patients. Moreover, we evaluated side-effects of lipid-lowering therapy.

METHODS

Patients admitted with STEMI at Jena University Hospital were started on atorvastatin 80 mg and ezetimibe 10 mg on admission. Patients were followed for EAS/ESC LDL-C target achievement during follow-up.

RESULTS

A total of 85 consecutive patients were enrolled in the study. On discharge, 32.9% achieved LDL-C targets on atorvastatin 80 mg and ezetimibe 10 mg. After 4-6 weeks, 80% of all patients on atorvastatin 80 mg and ezetimibe started at the index event were on ESC/EAS LDL-C targets. In 20%, combined lipid-lowering therapy was escalated with either bempedoic acid or PCSK9 inhibitors. All patients achieved LDL-C levels of or below 55 mg/dL during follow-up on triple lipid-lowering therapy. Combined lipid-lowering therapy was well-tolerated with rare side effects.

CONCLUSIONS

Early combination therapy with a high-intensity statin and ezetimibe and escalation of lipid-lowering therapy with either bempedoic acid or PCSK9 inhibitors gets potentially all patients with STEMI on recommended ESC/EAS LDL-C targets without significant side effects.